Healthcare Provider Details

I. General information

NPI: 1609699503
Provider Name (Legal Business Name): TIFFANY NICOLE DIAL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E NORTH AVE
BALTIMORE MD
21202-5984
US

IV. Provider business mailing address

9400 GRAND BLVD APT 2522
LARGO MD
20774-2664
US

V. Phone/Fax

Practice location:
  • Phone: 443-984-2000
  • Fax:
Mailing address:
  • Phone: 240-304-7526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: